What to include on your employer medical restrictions form

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The Saskatchewan Workers’ Compensation Board (WCB) is asking employers to include the following notation on the medical restrictions form (if you use one):

If this form is being used for a work injury at the initial visit, please bill WCB code 640.

Please supply your workers with a medical restrictions form. Workers should provide this form to their care provider during their first visit for return-to-work counselling.

This form outlines what the worker can or can’t do at work because of their injury. There are many names that are used to refer to a medical restrictions form. They include:

  • Fitness to return-to-work assessment
  • Return-to-work template
  • Medical absence report
  • Physician’s release to return-to-work form
  • Medical certificate employee absence-from-work form
  • Statement of medical restrictions form
  • Functional abilities assessment form
  • Medical assessment form
  • Health care provider’s assessment for functional abilities

If you have questions, please contact the WCB at 1.800.667.7590.

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WCB services